The pilot was conducting a trial instructional flight when the aircraft experienced an engine failure approximately 50 feet above ground, and three quarters of the way along the runway. The pilot was able to clear a large ditch at the end of the runway, and landed the aircraft in a cane crop. Inspection of the engine revealed that the engine failure was caused by the failure of a gudgeon bearing housing. The neoprene housing had jammed and broken up allowing needle rollers to escape into the crankcase and cylinder. The Bureau has been advised that the engine manufacturer is to replace the gudgeon bearing in the engine type with an improved version.

The pilot reported that he was making a landing approach in strong and gusty crosswind conditions. There was considerable turbulence in the area. On very short final the aircraft encountered an updraft. The pilot reduced power almost to idle, and the aircraft then entered an area of strong sink and lost airspeed. Although substantial power was re-applied, the pilot said he was unable to prevent the aircraft from contacting the runway in a nose-low attitude. The nose gear collapsed and the aircraft slid to a halt on the runway.

The aircraft was cruising at 400 feet above the ground when it suffered a complete engine failure. The pilot stated that the engine had cut out in a manner similar to being switched off. There was no rough running or misfiring, before the engine stopped. A single air restart was attempted without success. The pilot then elected to land in a dry creekbed, the only available cleared area within gliding distance. During the forced landing, the right main landing gear struck a rock. This resulted in a severe swing to the right during which the aircraft struck trees lining the creekbed. The aircraft was transported to a workshop at Mt Isa, where a successful attempt was made to restart the engine. The engine ran at low power settings, for some time with out fault. The owner restarted and ran the engine a further four times without incident. However, the engine fuel filter was later found to have been substantially contaminated with foreign debris. The fuel filter had previously been reinstalled in the reverse sense by the aircraft owner. This effectively contained all incoming contaminants on the inside of the filter screen tube, which caused a restriction to the fuel flow.

The pilot was spraying a bean crop in a valley. During a procedure turn the aircraft began to sink towards trees on the side of the valley. The pilot immediately applied full power and dumped the load, but the sink could not be arrested and the aircraft struck the trees. When the sink was encountered the pilot was committed to continue the turn to avoid terrain. The surface wind in the valley was a light southerly breeze, but there was a strong south-easterly at 2000 feet. The pilot had sprayed the field on previous occasions, and was familiar with the local area. The sink experienced on this occasion was considered to be the result of the strong wind at height combined with the local topography. This type of situation is documented in the Agricultural Pilots Manual. No faults were found with the aircraft that may have contributed to the occurrence. It was evident that when the sink occurred the performance available from the aircraft was insufficient to enable the pilot to avoid collision with the trees.

Circumstances:

The operator submitted an ICAO format flight plan direct to the Civil Aviation Authority (CAA) telecommunications network on the evening prior to the flight. This flight plan took into account a temporary change of routes in the Mackay area due to decommissioning of the Mackay VHF omni-directional radio range (VOR). The operator also advised the CAA Mackay briefing office of the sectors to be flown by the crew who would obtain briefing at Mackay. When the crew arrived for briefing the Briefing Officer had a set of notams and flight sector sheets available for collection. The crew advised him that they would be using the plan submitted by their company. The sectors for the crew that day were Mackay - Rockhampton - Brisbane - Townsville - Brisbane. All legs were flown uneventfully until the Townsville - Brisbane sector. The clearance for the aircraft was to track Townsville - Bowen then planned route. Radar coverage from Townsville is lost at 90 nautical miles just prior to Bowen. The aircraft was flown from Bowen to Mackay with the next point being Corio instead of Bowen to Hamilton Island then to Corio. The error was detected when the Hamilton Island position report was requested by Townsville Control. The investigation disclosed that the crew did not read the Notams received at Mackay. Those Notams contained a typed note concerning amended routes around Mackay due to decommissioning of the Mackay VOR and readers were directed to a Brisbane FIR Notam number 3600. That Notam was not in the package given to the crew. In any event it had been superseded by Brisbane FIR Notam 3667 on 1 August, and it was not given to the crew either. The company navigation officer is responsible for the routes flown by company aircraft. He had ensured that the flight plans relating to flights around Mackay took the amended routes into account. The pilots have two other sources of route data available. These are the flight planning books available at each CAA briefing office and the Flight Management Computer (FMC) sector details programmed into each aircraft. Neither of these were altered due to the effort required and the temporary nature of the changed routes. The only route effectively altered by the changes was the tracking of flights between Townsville and Hamilton Island instead of Townsville and Mackay. When the crew were checking the legs in the FMC on the ground at Townsville, they used the sheet given to them by the Mackay briefing officer. Since this agreed with the FMC legs, they had no reason to question the planned route. Had the flight plan been used as a check the different track would have been noted.

Significant Factors:

The following factors were considered relevant to the development of the incident:

1. The Briefing Officer did not provide a full Notam list for pre-flight briefing.

2. The operating company did not highlight discrepancies in route information to crews.

3. The pilots did not read the Notams.

4. The pilots did not use the ATC flight plan to check FMC data.

Recommendations:

1. When an aircraft is given an airways clearance the route to be flown is usually specified to the first turning point or a point along the cleared track. If the first reporting point was nominated all parties concerned would have a final check on the track the aircraft would fly. At the first reporting point the next segment of the route would normally be confirmed by the pilot's position report or the radar track of the aircraft. It is recommended that the Civil Aviation Authority amend the format of airways clearances to include the first reporting point instead of the first turning point or tracking point along a cleared route.

The pilot reported that the aircraft was flying at 50 knots at about 500 feet above the ground when the engine stopped. He pulled the engine start cord and the engine restarted. The aircraft was then climbed to 2000 feet as the pilot was concerned about operating over rough terrain. A short time later, the engine stopped again and rather than attempt another restart, the pilot concentrated on landing the aircraft. Substantial damage resulted from the landing on unsuitable terrain. Examination of the engine revealed that the carburettor was misaligned and that the piston at the magneto end of the engine had failed. The piston exhibited signs of detonation which was probably the result of an overly lean fuel/air mixture. Recent advice from the engine manufacturer included the recommendation that super grade petrol be used instead of unleaded petrol with ehtyl alcohol added. Further, new engines are fitted with a baffle or air guide under the cylinder cowl and have a new carburettor setting. This accident was not the subject of an on-site investigation.

Circumstances:

After take-off, the pilot had selected gear up. During climb, at about 1600 feet, he noticed that the red gear unsafe light was still illuminated, and by checking the nacelle mirror, that the nose gear was still extended. The wheel also appeared to be turned at an angle. The aircraft returned to Bankstown, where it was observed that the nosewheel was turned through about 80 degrees to the right. Use of full rudder travel and cycling of the landing gear failed to produce any change in the position of the nose gear, although the main gear retracted and extended normally. After seeking engineering advice, the pilot elected to land on grass and an area was prepared on the left of, and parallel to Runway 11 Left. He advised that he intended to shut down the engines on late final and position the propellers to preclude ground contact on landing. At about 200 feet on final approach, he closed both mixtures but had insufficient time to reposition the propellers. The aircraft dropped with a high sink rate and touched down 110 metres short of the intended landing area. On initial ground contact, the left main gear pushed up through the wing and broke off. The aircraft slewed to the left and the nose gear broke off during the 85-metre ground slide. It was found that the right hand nose wheel steering stop had been sheared, probably during ground handling operations. This resulted in detachment of the tiller roller from the steering channel and bending of the torque link pivot bolt. The torque link subsequently failed across the pivot bolt hole, allowing the nose leg to turn approximately 80 degrees.

Significant Factors:

The following factors were considered relevant to the development of the accident:

1. Rough ground handling by persons unknown, resulting in damage to the nose gear mechanism.

2. Overconcentration by the pilot on attempting to manipulate the position of the propellers.

3. Pilot failed to maintain sufficient speed on approach, resulting in undershoot and heavy landing.

Recommendations:

1. This is another example of a pilot causing a more serious accident by attempting to do the "right thing". For many types of emergencies, no guidance is given by the manufacturer. It is recommended that the Civil Aviation Authority publish an article in the Aviation Safety Digest on the landing techniques to be employed with certain undercarriage malfunctions, such as defective nose gear.

Circumstances:

The Adelaide Flight Data Officer was under training, but he prepared the strip for VH-TJD unsupervised. Due in part to the location of the strips and the pressure of attempting "to do a good job" the officer selected an Alice Springs to Sydney strip by mistake. This was passed to the controller. When the aircraft taxied at Alice Springs it was issued with a clearance by the Alice Springs Tower. Alice Springs then informed the Adelaide controller that the aircraft was taxiing for Adelaide and gave the cleared route and level. The Adelaide controller was busy at the time, but he read back the cleared level. This is an acknowledgement to the Alice Springs controller that he had understood the complete communication. The Adelaide controller did not hear the destination as Adelaide and seeing the strip assumed the aircraft was tracking to Sydney. Twenty one minutes after departing Alice Springs the aircraft was instructed by one Adelaide controller to call another Adelaide controller at position Kalug on the Sydney route. The aircraft captain queried the instruction and confirmed the aircraft was tracking to Adelaide. The pilot was then instructed to descend the aircraft to Flight Level 330 to remain clear of opposite direction traffic. On 12 April 1990 Adelaide Air Traffic Control issued Aeronautical Information Circular (AIC) 8/90 titled "Coordination of Clearances Between Alice Springs and Adelaide". This AIC requires Alice Control to include in its advice to Adelaide Control the first position report. Adelaide Control is required to read back that position while Alice Springs ensures the read back is correct. The same procedure is required both on taxi and departure.

Significant Factors:

The following factors were considered relevant to the development of the incident:

1. The Trainee Flight Data Officer was not supervised.

2. The Trainee Flight Data Officer selected an Alice Springs to Sydney strip in error.

3. The Adelaide controller did not correctly check the information on the flight progress strip.

Recommendations:

1. The Civil Aviation Authority should investigate better systems of supervision of Trainee Flight Data Officers.

2. The Civil Aviation Authority should examine all non-radar-controlled airspace to determine if the Adelaide AIC 8/90 of 12 April 1990 - Coordination of clearances between Alice Springs and Adelaide - should be extended to other airspace.

The piloo reported that the engine failed shortly after takeoff and that he was forced to land the aircraft on unsuitable terrain. The reason for the engine failure was not determined. This accident was not the subject of a formal on scene investigation.

A number of witnesses observed the aircraft operating in the accident area. A common observation was that it was operating at a lower height (probably between 500 and 1000 feet above ground level) than was usually seen of other light aircraft flying over the area. The aircraft was seen to complete a number of level orbits over a chicken farm and then to head south for about two kilometres. While this was occurring the engine sound died and picked up again a few times, as if the pilot was practising setting the aircraft into a glide. The aircraft then flew a level left turn through about 270 degrees before suddenly entering a 30 to 40 degree dive. At close to tree-top height it abruptly changed attitude and entered a steep, perhaps vertical, climb. Some witnesses felt that the pilot was about to fly a loop. As the aircraft climbed, the speed rapidly decayed. During these manoeuvres, the engine note was heard to die and pick up twice. The aircraft was then observed to fall, nose first and right wing slightly low, into a near vertical dive. Apart from completing one or possibly two rotations, it remained in this attitude until lost from sight amongst trees. The aircraft impacted the ground in a 90 degree nose down attitude. When recovered from the wreckage the airspeed indicator was indicating 105 knots. It was established that the engine was operating at impact. No evidence was found of any abnormality in the aircraft or its systems which may have contributed to the accident. No explanation was found for the apparent operation of the aircraft at a relatively low height, or for the dive to a very low level followed by the steep climb. The carburettor fitted to the engine was equipped with an accelerator pump. A characteristic of carburettors of this type is that rapid or "slam" opening of the throttle can temporarily over-fuel the engine and cause the RPM to fluctuate for a short time. It could not be determined whether this characteristic may have been associated with the engine note dying and picking up twice as heard by witnesses in this instance. Investigation established that the the passenger occupying the front right-hand seat had flown 33 hours dual and 3.5 hours solo on Cessna 152 aircraft during 1983/84. The front seats of the aircraft were adjustable fore-and-aft along rails attached to the floor. Examination of the cockpit revealed the adjustment of the front left-hand seat (occupied by the pilot-in-command) at impact to have been five notches from the front. The front right seat was positioned in the forward-most notch. Tests of these seating positions were conducted in another PA28 aircraft using persons of the same height as those involved in the accident. These tests indicated that the right seat occupant should have been able to comfortably manipulate the engine and flying controls of the aircraft. However, the left seat appeared to be too far to the rear for the pilot-in-command to have been in a normal flying position in relation to the controls. Specific flying techniques are required to recover an aircraft from an extremely nose-high attitude at low speed. The aircraft involved in this accident was observed to develop such an attitude accompanied with low speed, and the low height at which this occurred would have increased the level of pilot skill required to return the aircraft to a safe flight environment. It was established that the pilot-in-command had received no training in the flying techniques required to recover aircraft from unusual attitudes. The seating position tests suggested that the pilot-in-command may not have been manipulating the controls during the final stages of flight, and it is also probable that the person occupying the right-hand seat had not received any training in recovery from unusual attitudes. It is considered probable that once the aircraft had reached the nose-high attitude at low speed, that it was beyond the experience level of either of the front seat occupants to effect a safe recovery, particularly in view of the low height of the aircraft at the time.